I. The Employment of Local Anæsthesia in the Radical Cure of Certain Cases of Hernia, with a ...

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ANNALS OF SURGERY.
THE EMPLOYMENT OF LOCAL ANAE:STHESIA IN
THE RADICAL CURE OF CERTAIN CASES OF
HERNIA, WITH A NOTE UPON THE NERVOUS
ANATOMY OF THE INGUINAL REGION.
By HARVEY CUSHING, M.D.,
OF BALTIMORE,
ASSOCIATE IN SURGERY, THE JOHNS HOPKINS UNIVERSITY.
[FromtheSurgicalClinicofProfessorHalsted.]
A BRIEF report was made before the Johns Hopkins
Hospital Medical Society in May, I898, on the propriety of
using a local anaesthetic while operating upon certain cases of
hernia, when the patient's age and physical condition seemed
to prohibit general narcosis.
Since our first cocaine operation, December 6, I897, to the
present time, December 6, I899, 233 herniotomnies have been
performed, forty-nine of them under regionary anasthesia.
These latter cases have been operated upon by Professor Hal-
sted, Dr. Bloodgood, and the writer, and, for a variety of
reasons, in the majority of them the administration of ether or
chloroform seemed inadvisable or positively contraindicated,
whereas, in the remainder, the local anaesthetic was employed
at the patient's personal request.
Almost all cases of hernia, with the possible exception of
those in young children, could undoubtedly be subjected to the
radical operation under similar local methods, but when a gen-
eral anwesthetic can safely be administered, for various reasons
itis much to be preferred byboth patient and operator. Under
I
2 HARVEY CUSHING.
local anaesthesia some pain is necessarily inflicted, and to spare
the patient, it is a temptation to slight certain steps of an elab-
orate plastic operation. Furthermore, the operation necessarily
consumes more time,and the responsibility ofbolstering up the
patient's courage is often most wearing on the surgeon. This,
however, is not invariably the case, since personal inhibition
towards pain varies so greatly with the individual. As Gott-
stein says, " Die Schmerzempfindung bei verschiedenen Men-
schen verschieden ist," and many people readily submit to the
slight immediate suffering incidental to operative procedures
under local anaesthesia in preference to enduring the discom-
forts secondary to general narcosis.. For those individuals
who endure pain with but slight control, it is fortunate that
there are certain adjuvants, such as the preliminary adminis-
tration of morphia and occasional inhalations of chloroform
during the operation, which may render the objections to the
local method less valid, but, nevertheless, the anasthesia of
choice will continue to be a general and not a local one.'
In certain conditions, however, complete narcosis is con-
traindicated, and it is my object to report the results of our
observations upon cases which have been operated upon under
these circumstances.
Advanced age, chronic bronchitis and emphysema, tuber-
culosis laryngeal or pulmonary, cardiovascular changes of
I Since thisparagraph waswritten observations upon the nervous anatomyof
theinguinal region,reviewed inthelatterpartofthispaper,havesogreatlyassisted
us in the performance of a painless operation that the above statements may be
qualified to a considerable degree. During the fall of I899, twenty-four herni-
otomieswith cocaineor eucaine fl have been performed in young men practically
withoutpain, and this procedurehasbecomesopopularizedinthe wardwhereour
herniacasesareadmittedthattheoperationunderthelocalanssthetichasbecumethe
operationofchoice. Anindividual awaitingoperationneedstoremainintheward
onlylong eneugh to compare the convalescenceof anethercase and thatof one
doneunder cocaineto choosethelattermethodforhimself. Thesepatientsusually
regard the shaving and skin preparation asthe most trying partof theoperation.
Mostof theobservations on cutaneous ansesthesia have been madeonthesecases
duringthe operation and immediatelyafterclosing thewound. Ithasbeenfound
thatthepatient can assist not a little in certain stepsofthe operation, as,forex-
ample,whentheneck of thesacisclosed, inmaking negative abdominal pressure
toprevent the omentum, orbowel, frombeingpusheddownbetweentheperitoneal
sutures.
LOCAL AN.ESTHESIA IN RADICAL CURE OF HERNIA. 3
marked degree, chronic nephritis, and,above all, the shock and
vomiting in strangulation have been factors in the selection of
these cases. One of Dr. Bloodgood's patients was eighty-four
years of age, and operative intervention for his large uncon-
trollable hernia had been refused him several times. In an-
other case the local anaesthetic was chosen because a previous
administration of ether for the purpose of operating on a sup-
purative ethmoiditis had almost resulted in a death on the
table. Another case was that of a sickly child with broncho-
pneumonia and an incarcerated congenital hernia; another, a
case with tuberculous laryngitis. Other specific illustrations
might be given,but, as will be seen on consulting the appended
table, the two conditions which have been chiefly responsible
for the avoidance of inhalation methods of anaesthesia have
been (i) the combination of arteriosclerosis with cough from
chronic bronchitis and emphysema in patients past middle life,
and (2) the shock and vomiting associated with strangulation.
During the past eighteen months, in Dr. Halsted's house-
service, about 2oo cocaine operations have been registered,
many of them major operations, and often upon patients to
whom, for reasons similar to those reviewed above, it seemed
unwise to administer ether or chloroform. About thirty lapa-
rotomies have thus been performed under local anaesthesia;
several exploratorysections; two gastrostomies bytheSsabane-
jew-Frank method; closureofatraumatic ruptureofthejejunum;
three cholecystostomies for empyema ofthe gall-bladder; three
appendectomies, one acute case in a patient with extensive
bronchiectasis and osteo-arthropathy, a second, an "interval"
operation through a McBurney incision in a young man with
tuberculous laryngitis, and the third case, the removal of a
chronic appendix, with adhesions, which had given abdominal
symptoms, supposed to be perforative, in a patient with typhoid
fever. On September 7, of this year, the writer, under cocaine
ancesthesia, operated and closed one perforation of the ileum
in a typhoid case, and inverted two other suspiciously thin
Peyer's patches. I succeeded without difficulty in resecting a
pylorus for carcinoma in an old woman who had a large cavity
in one lung, and again, in doing a gastro-enterostomy, by a
4 HAARVEY CUSHING.
method similarto Roux's, which required adouble suture. It is
extraordinary that handling, resecting, and suturing the bowel
should be unattended by pain. Lilienthal has called attention
to this. The same may be said of the omentum. In oneher-
niotomy a large mass, the size of two fists, was excised with-
out pain. Cocainization of the gut has never been necessary.
Any attempt to drag upon the bowel, however, does cause pain
similar in character to that of peristaltic cramp. This has
been observed several times in handling strangulated loops,and
in one of the appendectomies referred to, while lifting up.the
organ to free it from the surrounding adhesions, pain, referred
to the epigastrium andresemblingthepatient's previous attacks
of appendicular colic, was occasioned. Amputation of the ap-
pendix, however, has always been painless.
A great number ofminor operations are, ofcourse, readily
performed under local anaesthesia, and it is consequently very
largely employed in out-patient clinics. In dealing with the
large group of thyroid enlargements and growths in the neck,
in which there is any tracheal compression, Kocher has dem-
onstrated cocaine to be almost a sine qua non of operation.
Local anaesthesia is especially suitable for such operations as
the ligation of varicose veins, suprapubic cystostomies, even in
patients who might safely take an anaesthetic, and all scrotal
operations, as for varicocele, hydrocele, castration, etc., are
simply performed through the high incision which is employed
at this hospital, provided the ileo-inguinal nerve is previously
cocainized in the canal. This will be dwelt upon later.
It is the writer's intention, however, to confine himself
chiefly to the hernia group of cases, and accordingly they have
been tabulated, with some of the most important data relating
thereto.
TABLE OF HERNIOTOMIES PERFORMED UNDER LOCAL ANAESTHESIA BY
COCAINE.
(In this list those cases alone are included in which a general anms-
thetic, for the reasons given in the table, seemed contraindicated. The
twenty-four cases in which cocaine was simply the anaesthetic of the
patient's selection arenotincluded.)
CASE I.-Surgical No. 7I96, December 6, I897, Cushing.- Age. fifty-
LOCAL AN.&STHESIA IN RADICAL CURE OF HERNIA. 5
three years, male. Character ofhernia, large left inguinal; strangulated
forty-eight hours; viable bowel. Reasonfor selection oflocal anesthetic,
arteriosclerosis; shock andvomiting of ileus. Characterofoperaton, sim-
ple relief of strangulation with reduction; closure (radical cure ata later
date). Complications, none. Result, healingperfirimam; well.
CASE II.-Surgical No.7623,April 21, I898, Cushing. Age,sixty-seven
years, male. Character of hernia, large right inguinal; recently incar-
cerated. Reason for selection of local anesthetic, chronic bronchitis an
emphysema; arteriosclerosis (extreme); chronic nephritis. Character oj
operation, radical cure; simple closure of abdominal wall after section of
spermatic cord. Complications, none. Result, healingpferPrimam,; well.
CASE III.-Surgical No. 7652, April 27, I898, Cushing. Age, thirty-
nine years, male. Character of hernia, large left inguinal; strangulated
six hours; bowelviable. Reasonforselection oflocal angsthetic, frequent
vomiting of ileus; shock. Characterofofieration, radical cure; section of
spermatic cord, as testicle was atrophied. Complications, some swellingof
testicle. Result, healingfierfrimam; well.
CASE IV.-Patient of Dr. Gaver, May i, I898, Cushing. Age, fifty
years, female. Characterofhernia, small right femoral; strangulated three
days; bowelviable. Reasonforselection oflocal anesthetic, no assistant.
Characterofoperation,radical cure. Comilications, none. Result, healing
perprmam; well.
CASEV.-SurgicalNo.7769, June8, I898,Bloodgood. Age,sixty-seven
years, male. Characterofhernia, small leftinguinal. Reasonforselection
of local anevsthetic, age and chronic nephritis. Character of operation,
radical cure; section of cord; transplantation of rectus muscle. Complica-
tions, some swelling of testicle; hamatoma. Result, well.
CASE VI.-Surgical No. 7777, June 8, I898, Bloodgood. Age, fifty
years, female. Character of hernia, small right femoral; strangulated;
bowel viable. Reasonfor selection oflocal anesthetic, frequentvomiting.
Character ofoperation, radical cure. Complications, none. Result, heal-
ingfierpimam,; well.
CASEVII.-Surgical No. 7804, June 13, I898, Bloodgood. Age, fifty-
two years, female. Character of hernia, large umbilical; symptoms of
strangulation, four days; bowel viable. Reasonforselection oflocal anes-
thetic, obesity; frequent vomiting. Character ofoperation, radical cure;
wound drained. Complications, continuance of vomiting; diarrhcea, etc.
Result, healingperprimam andfiersec.; well.
CASEVIII.-Surgical No. 786I, July6, I898, Bloodgood. Age, eighty-
threeyears, male. Character ofhernia, very largeright inguinal. Reason
for selection oflocal anesthetic, age; arteriosclerosis; aortic insufficiency.
Characterofoperation, radical cure,with rectustransplantation; castration.
Complicatons, none; catheterized once. Result, healing pier primam;
well.
CASE IX.-Surgical No. 8102, September ii, I898, Cushing. Age,
sixty-fiveyears, male (colored). Characterofhernia, small rightinguinal;
6 HARVEY CUSHING.
strangulated ten hours; bowelviable. Reasonfor selection oflocal anacs-
thetic, condition good; might have hadgeneral anesthesia. Characterof
operation, radical cure; Bassini's operation. Complications, none. Result,
healingierprimam; well.
CASE X.-Surgical No. 8269 (cf. 786I), October 25, I898, Bloodgood.
Age, eighty-four years, male. Character of hernia, small left inguinal.
Reasonfor selection oflocal anasthetic, age; arteriosclerosis, etc. Char-
acter ofoperation, radical cure; simple closure after excision of sac and
section of cord. Complications, none. Result, healingperprimam; well.
CASE XI.-Surgical No. 8392, December 2, I898, Bloodgood. Age,
sixty-two years, male. Character ofhernia, large right inguinal. Reason
for selection of local anasthetic, shock of ileus; vomiting. Character of
operaton, simple relief of strangulation; suspicious gut left in wound.
Complications and result, death from pneumonia, following chloroform
administration, the following day, given during resection of suspicious
bowel.
CASE XII.-Surgical No. 8445, December 28, I898, Cushing (cf. re-
ported in full). Age, seventy-one years, male. Characterofhernia, large
right inguinal. Reasonfor selecton oflocal anasthetic, chronic bronchi-
tis with emphysema; cardiac hypertrophy; arteriosclerosis; alcoholism.
Character ofoperation, radical cure; simple closure after excision of sac
and section of cord. Complications, pleurisy; cardiac insufficiency tem-
porary; considerable abdominal distention. Result, healingperprimam;
well.
CASEXIII.-Surgical No. 8445, January 30, '899, Cushing. Age, sev-
enty-one years, male. Character of hernia, large left inguinal. Reason
for selection of local anesthetic (given above, Case XII). Character of
operation, radical cure; simple closureafter excision of sacand section of
cord; transplantation of rectus. Complications, none. Result, healingfper
pinmam; well.
CASEXIV.-Surgical No. 8511, January 12, I898, Cushing. Age, fifty
years, male. Characterofhernia, largedirect inguinal. Reasonfor selec-
tionoflocal anarsthetic, chronic bronchitis and emphysema; myocarditis.
Characterofoperation, radical cure; Halsted's operation; a few whiffs of
chloroform necessary for closure. Complications, none; catheterization
required twice. Result, healingperprimam; well.
CASE XV.-Surgical No. 8591, February I, I899, Professor Halsted.
Age, seventy-two years, male. Character ofhernia, small right inguinal.
Reason forselecion of localanasthetic, arteriosclerosis. Characterofopfer-
ation, radical cure; transplantation of rectus. Complications, abdominal
distention and pain for some days, probably from preliminary morphia.
Result, healingper primam; well.
CASEXVI.-SurgicalNo. 86ig,February i5, i899,Cushing. Age,sixty-
eight years, male. Character of hernia, large right femoral. Reasonfor
selecton oflocalanesthetic, chronic suppuration of ethmoidcells; hadpre-
viously nearly succumbed to ether. Character ofoferation, radical cure;
LOCAL ANASTHESIA IN RADICAL CURE OFHERNVIA. 7
Halsted's method by granulation. Comfilications, none; cathlterization
necessary during recumbency; hypertrophied prostate. Result, healing by
granulation; well.
CASE XVII.-Surgical No. 8630, February 6, I899, Cushing. Age,
fifty-nine years, female. Charactrofhernia, smallleftfemoral; incarcer-
ated ten days; bowel viable. Reasonfor selection oflocal anasthetic,ex-
treme prostration. Character of oietation, radical cure. Compications
and result, death on second day; continuance of prostration, subnormal
temperature.
CASEXVIII.-Surgical No. 8726, March7, i899, Cushing. Age, three
andone-halfmonths, male. Characterofhernia, rightcongenital; strangu-
lated; viable. Reasonsfor selecton of local aneesthetic, double broncho-
pneumonia. Characterofoperation,radical cure. Complicationsandresult,
death onsecond day; broncho-pneumonia antedating operation. Autopsy.
CASE XIX.-Surgical No. 908i, June i8, I899, Cushing. Age, sixty-
eight years, male. Character ofhernia, large right inguinal, with hydro-
cele. Reasonforselection oflocalanasthetic,chronicbronchitis. Character
ofofieration, radical cure; simple closureafter excision of sac and section
of cord; excision of hydrocele. Complicatons, none. Result, healing per
primam; well.
CASEXX.-SurgicalNo. 8754, March21, I899,Cushing. Age,seventy-
six years, male. Character of hernia, small right inguinal; strangulated
fourdays; gangrenous. Reasonforselectionoflocalanasthetic, pronounced
shock and vomiting; bronchitis; chronic nephritis; arteriosclerosis; ster-
coraceous vomiting. Characterofoperation, simple relief of constriction;
establishment of artificial anus. Complications and result, resection of
bowel and endto-end suture, under cocaine, on second day; death from
broncho pneumonia sixth day. Autopsy, peritoneum sterile; sutureintact.
CASE XXI.-Surgical No. 9228, July 28, i899, Cushing. Age, fifty-
eight years, male. Character ofhernia, very large left inguinal. Reason
forselecton oflocalanasthetic,chronicbronchitis andemphysema; arterio-
sclerosis; alcoholism. Characterofoperation, radical cure; simpleclosure
afterexcision ofsac andcastration. Comfplications, none. Result, healing
perpinmam,; well.
CASE XXII.-Patient of Dr.. Ellis, August 3, I899, Cushing. Age,
fifty-fiveyears, female. Characterofhernia, small rightfemoral; strangu-
lated three days; gangrenous. Reason for selection of local anasthetic,
prostration; vomiting. Character of operation, excision of gangrenous
area; establishment of artificial anus; subsequently admitted to house for
operation. Complications, none. Resul, August 24, I899, resection of
bowel; lateral anastomosis; peritoneal closure withoutdrainage; recovery.
CASEXXIII.-Surgical No.9274,August 5, 18990Gushing. Age,forty-
fiveyears,male. Characterofhernia,largerightinguinal; strangulatedthree
days; viable. Reasonforselection oflocal anacsthetic, pronounced shock;
hiccough and vomiting; arteriosclerosis. Characterofoperation, relief of
constriction; reduction of dark suspicious bowel (free fluid in sac contain-
8 HARVEY CUSHING.
ingcolon bacilli); division at neck of sac and closureof peritoneal cuff;
rest of wound left open. Complicatons, none. Result, radical cure ten
days later, by Dr. Mitchell; ether anaesthesia; closure; healing Pet
primam,; well.
CASEXXIV.-SurgicalNo.9I82,July I5, I899, Cushing. Age,seventy-
oneyears,male. Characterofhernia,largerightinguinal. Reasonforselec-
tionoflocalanosthetic, age; arteriosclerosis; chronic bronchitis andemphy-
sema. Character ofoperation, radical cure; simple closureof abdominal
wall afterdivision of cord, with transplantation of rectus muscle. Compli-
cationsandresult, slight swelling of testicle; healingperfrimam; well.
CASE XXV.-Surgical No. 9323, August 24, I899, Cushing. Age,
sixty years, male. Character of hernia, small right inguinal, with large
hydrocele. Reasonfor selection of local anesthetic, age; arteriosclerosis.
Characterofoperation, radical cure; simpleclosureofabdominal wall after
removal of hydrocele and castration. Complications, none. Result, heal-
ingpferprimam; well.
CASE XXVI.-Surgical No. - , September i6, I899, Cushing. Age,
forty-eight years, male. Characterof hernia, largerightinguinal. Reason
forselection oflocalanasthetic,obesity; fattyheart. Characterofoperation,
radical cure; simple closure after division of cord; difficult operation from
fattissue. Complications, none. Result,healingbyprimaryunion; super-
ficial fat necrosis threatened; wound did not open, though lineof incision
discolored; well.
CASEXXVII.-Surgical No. 9447, September 26, I899, Cushing. Age,
fifty-three years, male. Character of hernia, very large right inguinal.
Reasonforselection oflocalanesthetic, bronchitis andemphysema; arterio-
sclerosis. Character ofopieration, radical cure; closure with transplanta-
tion of rectus muscle after division ofcord. Complications, none. Result,
healingperfipmam; well.
CASE XXVIII.-Surgical No. -,September 30, I899, Cushing. Age,
thirty-three years, female. Characterofhernia, strangulated rightfemoral,
twodays; bowelviable. Reasonforselectionoflocalanesthetic,prostration.
Characterofoperaton, simplereduction ofstrangulated gut; no attempt at
closure; gauze pack. Complications, none. Result, healing bygranula-
tion; well.
CASE XXIX.-Surgical No. 9531, October 30, I899, Mitchell. Age,
seventy-five years, male. Character of hernia, large right inguinal with
hydrocele; strangulated six hours; bowel viable. Reasonforselection of
localanesthetic,ageandstrangulation. Characterofoperation,radicalcure,
with castration. Complicatons, none. Result, healingperfirimam; well.
CASE XXX.-Surgical No. 9523, October 27, I899, Mitchell. Age,
seventeen years, male. Characterofhernia,congenitalrightinguinal,with
undescended testicle; strangulated twelve hours; bowel viable. Reason
for selection of local aneasthetic, shock, vomiting, leucocytosis of 43,000.
Characterofoperation, radical cure, withtransplantation of testicle. Com-
plications, none. Result, healingperpfimam; well.
LOCAL ANAISTHESIA IN RADICAL CURE OF HERNIA. 9
Many of the cases included in this table represent patients
who would have been refused operation a few years ago. In
his report on hernia, Bloodgood says (The Y7ohns Hopkins Hos-
pital Reports, Vol. vii, p. 334), relative to the days before we
began the use of local anoesthesia, "In patients over fifty years
ofage,suffering from non-strangulated hernia,we have selected
our cases because of the possible danger from the anawsthetic."
Bull and Coley likewise regard sixty years of age as a contra-
indication for the operation (ANNALS OF SURGERY, I898, P. 598).
The preceding table shows that under local anasthesia, in the
past few months, there have been fourteen patients over sixty
years of age who have been operated upon not for emergency
reasons, but from choice.
The citation of a few particular illustrations in greater
detail will, perhaps, better elucidate the reasons for avoidance
of general anaesthesia upon which we have just generalized.
These cases naturally fall irnto two groups: (i) those in which
the operation is not absolutely necessary,but done on accountof
the annoyance of the hernia; and (2) the cases ofstrangulation
inwhich there is urgent demand for intervention. The femoral
operation and that in women offers so little difficulty under a
local anaesthetic that I will dwell only upon the more difficult
conditions occurring in the male. Nos. XII and XIII of the
tablerepresent the typeofcombination ofadvancingage,cardio-
vascular changes, chronic bronchitis, and an associated annoy-
ing rupture. The case is as follows:
CASE.-Edward I., aged seventy-one years, an attorney, had
suffered from a double inguinal hernia for forty years. It had always
given him considerable pain, and at times had incapacitated him
from the practice of his profession. He had worn a double truss for
years, but it rarely controlled the ruptures for more than a few hours
at a time. He suffered greatlyfrom chronic constipation, aggravated
by his inability to strain at stool, and on several occasions, during the
past few years, one of the hernias had become incarcerated. The
patient had for years used alcohol to excess.
Physical examination showed an old man with evidences of
chronic alcoholism. His skin was loose, with panniculus abundant,
and the tissues generally were very flabby. There was marked pul-
IO HHARVEY CUSHJNG.
monary emphysema, sufficient to obliterate the area of cardiac dul-
ness, and over the praecordia a harsh systolic murmur could every-
where be heard. The radial pulse was small and difficult to palpate.
The abdominal walls were very lax (cf. Fig. I), and even in recum-
bencytheleastmovement caused thelarge bilateral inguinal hernias to
protrude after they were once reduced.
A note on the local condition reads as follows: "Both hernias
are complete and descend to the bottom of the scrotum, twenty
centimetres below the external rings. During their protrusion the
scrotum measures thirty-seven centimetres in circumference. The
hernia on the right, the larger, attains the size of an infant's head.
It contains bowel which is easilyreducible. The external ring readily
admits the tips of two fingers. The pillars are strong; they close
somewhat when the patient's head is raised from the bed, and there is
present a well-marked conjoined tendon.
"On the left, the sac also contains bowel, which feels doughy,
and is reduced with a little more difficulty. (This proved subse-
quently to be a large coil of sigmoid flexure full of faeces, evidently a
large factor in his chronic constipation.) The external ring is large,
readily admits the tips of three fingers, which pass directly through
the parietes overthe brim ofthe pelvis. The ring shows no tendency
to close when the patient raises his head, and there is no evidence of
a conjoined tendon. The testicle may readily be reduced, together
with the sac and its contents, through this opening in the parietes."
These hernias were operated upon, one at a time, with a month's
interval, as follows:
Right hernia, December 28, I1898: Radical operation under
cocaine anaesthesia with preliminary one-eighth grain of morphia.
The usual high incision was made through the fat abdominal wall
down to the aponeurosis, which was split outward from the ring to
expose the internal oblique muscle. This was flabby and pale, and
was not incised as under ordinarycircumstances. After cocainization
of the nerves the sac was exposed, divided at its neck, and the large
peritoneal opening having been closed, the fundus of the sac was
stripped from the scrotum as usual. Considering the patient's age
and the need of a strong parietes rather than an intact vas deferens,
the cord was divided and the abdominal wall' closed without Blood-
good's transplantation of the rectus, since there was a firm conjoined
tendon to protect the lower angle. Although the patient had had a
preliminary training in recumbency before the operation, he bore his
early enforced rest in bed badly. Some evidence of hypostasis in